PROJECT K9 SERVICES
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Personal Information
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Indicates required field
Name
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First
Last
Phone Number
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Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Application Type
What services are you hoping to receive?
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Dog Food
Transportation
Exercise
Emergency Boarding
Grooming
K9 Medical Needs
Gift Basket
Service Information
Branch of Service
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Army
Navy
Air Force
Coast Guard
Marine Corps
General Law Enforcement
N/A
Status
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Active
Retired
Guard/Reserves
Government Employee
Veteran
Spouse
N/A
Rank
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Military Discharge Category
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Honorable
Other than Honorable
Medical
Years of Service
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Public Service Area
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Military
Police
Fire
EMS
Spouse
Other
N/A
Conflicts Served In
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Employment
Are you currently employed?
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Yes
No
If yes, please include employer and average weekly hours.
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How long is your K9 left alone?
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Living Situation
How many people reside in your house?
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Rent or Own
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Rent
Own
Do you have a fenced in yard?
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Yes
No
Ages of those persons
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Less than 13
13-18
19-25
26-35
36-50
Over 50
K9 Information
How many dogs do you have?
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Please list Names and Ages
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Have you ever re-homed a dog?
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Yes
No
If Yes, please explain the situation. If No, put N/A.
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Applicant Survey
please describe why you chose Project k9 services and anything else you would like us to know to better understand your application.
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Would you be willing to speak with media/press, share photos/videos, and speak with our partners to help us continue our work?
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Yes
No
Maybe
How did you here about Project k9 Services (pk9s)?
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Internet Search
Instagram
Facebook
Friend
Other
T-shirt size
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S
M
L
XL
XXL
Shared Information Consent
Please read the Shared Information Consent Agreement in full and agree below:
By submitting this application I hereby give the Project K9 Services (PK9S) Staff, authority to use the information (including my participation in the PK9S program, verbal testimonies, quotations, photos, emails, text messages or any communication of any kind) shared by me on this day (the application date) or any day thereafter in any corporation-related promotional material including the PK9S websites, brochure, media, press releases, and merchandise.
I acknowledge and agree that PK9S, or others operating on behalf of PK9S may disclose to the public information that I provide to PK9S or its agents, including my Protected Health Information ("PHI"). This PHI may include my name, birth date, address, telephone number, diseases and ailments, medical records and treatment information. This agreement to disclose applies to any PHI governed and protected by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the Health Information Technology for Economic and Clinical Health (“HITECH”) Act, as amended, and under the rules and regulations thereunder, as well as applicable state law.
PK9S may use and disclose the information provided, including PHI, for the business purposes of PK9S, including but not limited to education, fund raising, advertisement of PK9S, and support of other veterans and individuals who PK9S assists.
With respect to (1) all video footage, photographs recordings, and written materials provided by me to PK9S in connection with the Project K9 Services program; and (2) all print, video, film, recordings and written materials prepared by PK9S or its representatives in connection with the Project K9 Services program in which I appear or am referenced, including, but not limited to, photographs, print materials, commercials, film or video, social media posts, posting on websites or webcasts ((1) and (2) of this paragraph shall collectively be referred to as "Works"), I hereby grant to PK9S and its designees, including assignees and others that PK9S collaborates with, the unrestricted, perpetual, worldwide right to reproduce, copy, modify, create derivative works and otherwise use, display, distribute, exhibit, transmit and broadcast the Works or any part thereof in any media, means or embodiment, now known or hereafter to become known, including my voice, image and identity without further approval or payment to me of any kind. I also hereby waives any right of inspection or approval of my appearance in the Works.
I read and agree to the shared information consent agreement
*
I agree
Name
*
First
Last
Todays Date
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(mm/dd/yyyy)
Supporting Documents
Please send us an email to our secure address of the following documents that supports your information listed above.
"team@projectk9services.com"
Copy of a government issued ID
OR
VA Identification Card
DD214 (Member 4 copy)
OR
current LES
Place of Rental Agreement
OR
proof of home ownership (
Rental agreement must contain applicants name and pet addendum. Home ownership documentation must contain applicant's name.)
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WHY WE DO IT
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